It’s time for a new paradigm: the materna-centered model of care

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The 20th Century was a golden age for maternity care. With the advent of modern obstetrics, childbirth went from a routinely deadly event to a rarely deadly advent. A myriad of interventions, from antibiotics to blood banking, from safer anethestia to safer C-sections, from neonatal ventilators to surfactant led to a 99% drop in maternal mortality and a 90% drop in neonatal mortality. The medico-technocratic model of maternity care has been a stunning success.

But the medico-technocratic model of care placed the the convenience of physicians ahead of maternal autonomy, and the midwifery model of care was advanced as a corrective. The midwife model of care put the focus back on women’s experience. Once childbirth was routinely safe, it made sense to focus on more than whether the mother and baby survived the experience. The midwife model of care acknowledged that many practices existed merely for physician convenience and offered no benefit for women and perhaps harmed them, or at the very least was cold and impersonal. Making sure that mothers are awake and aware for the birth of their children, inviting partners and other family members in for the birth, and rigorous investigation of routine maternity practice dramatically improved women’s experience.

Although the midwife model of care has brought improvements, it suffers from a similar problem as the medico-technocratic model of care. It still puts the provider at the center of care. The midwife model takes the core beliefs of midwives as incontrovertible fact, specifically the idea that there is a “best” way to give birth and that best way involves as little technology as can possibly be used. Midwives start with the bedrock assumption that unmedicated vaginal birth is the ideal and anything else represents a deviation from ideal. It uses midwives beliefs as its starting point, and that’s the wrong place to start.

I propose a new model of childbirth care for the 21st Century: a materna-centric model of care. A materna-centric model would take the best features of the two previous models, the dramatic improvement in safety wrought by the medico-technocratic model, and the focus on experience provided by the midwife model, but it would locate mothers at the heart of maternity care, their views, their values, their desires. The materna-centric model of care would have as its fundamental premise the idea that birth experiences are contingent on maternal culture, values and personal experiences. When you place the mothers values at the center, it is obvious that there is no best way to give birth; there is only what the mother prefers.

There is no need to glorify vaginal birth, and no reason to valorize refusing pain relief. The model is both culturally sensitive and personally sensitive. What constitutes a good birth is going to be different for a woman from Southeast Asia than for a woman from the US Southeast. What constitutes a good birth for a woman from a fundamentalist religious sect is going to be different from a good birth for a woman who works in the tech industry. Nobody is wrong. And, most importantly, no one’s birth choices make her superior to anyone else.

It may be helpful (albeit imperfect) to draw an analogy between maternity providers and interior decorators. Obstetricians can be understood as decorators who limit their designs to spare and functional choices. They decorate houses with every piece of furniture you need, but much of it is drab, and some of it is not comfortable. Midwives go beyond obstetricians in that their designs are colorful and comfortable. There’s just one problem; they only decorate in their preferred style, shabby chic. The equivalent of the new maternity provider (doctor or midwife) would be a decorator who decorates in the style that the client prefers, not the style that is most convenient for the decorator or most pleasing to the decorator.

The midwife model of care is outdated because it places the midwife at the heart of maternity care. As a result, it serves the needs of midwives, but leads to unnecessary suffering and tremendous guilt on the part of mothers. We need a model of maternity care that places mothers squarely at the center of care, and uses their values as the touchstone for decisions, not the provider’s values.

In other words, we need a materna-centered model of care.

  • CanDoc

    Yes, yes, yes. Although it can be difficult with delivery volumes that reduce labour and delivery to “widget-making” in terms of process, there are myriad small things that we can do to focus on maternal autonomy and informed decision making. Thank you for this post.

  • LaurainRedding

    The system is just not set up for patient and Dr relationship. It is more about insurance the “movements” by the natural birthing community just hurts things, so do insurance companies, both coverage for the patient and also liability insurance. Honestly I was surprised that my first ob appt was actually not with a dr but to talk about what my insurance covers and how much I would pay out of pocket. I gladly had a csec with my first it was the safest option, however I wanted to try for a VBAC with my second I was a good candidate, but I didn’t want to fight against anybody, however that was the position I was put into. For most of my pregnancy I tried to convince myself a repeat would be better, I failed at that one and still wanted a VBAC after looking into all the risks the symptoms of a uterine rupture. Thought I had rights as a patient they were all violated and ultimately was not a safe environment to give birth without communication with the DR and nurses. I was surprised at the emotional toll it took on me as well. It is great when I hear positive stories but many are not and unfortunately are turning to the wrong outlets to complain. I have no complaints about the OB they all lie with the hospital policy.

  • KarenJJ

    One of the biggest fears I had prior to childbirth was that I would not be listened too in a hospital during labour. I work in a very male dominated field. I’m used to being spoken over or ignored by some men. I’m lucky that even though my obgyn was blunt and his bedside manner was not the easiest, he did actually remember the important things I wanted and did offer me choices during labour. Luckily our key aims also aligned – I was very twitchy and wanted my baby out and healthy and more than happy for technology to help achieve that.

    I suspect I got a bit cocky after that and expected that I’d feel listened to, so I was baffled when I encountered the child nurses/midwives who knew what was best for my baby and refused formula when I requested it (I’d ticked ‘breastfeeding’ on the form but apparently wasn’t committed enough) and even refused info on bottle feeding when I asked for it (in case I suddenly caved when breastfeeding got ‘too hard’). It was a an eye-opener. I described to my husband that I was feeling like a “naughty pre-schooler” for asking.

  • Angie

    In the UK we will have to break through the “turf wars” between Obs and Midwives, between Midwives and Mothers before we have the ideal model of care. It’ll be a tough journey trying to unravel this unhealthy dangerous mess. We are ever hopeful.

  • Allie P

    Wait, what????
    My OBs have always been wonderfully caring, interested in my mental and emotional state as well as my physical one, happy to listen to my concerns and questions, and the hospital where I gave birth to my last child was more well-appointed than some hotels I’ve stayed in. I reject the party line that OBs are cold/unfeeling/only concerned about the bottom line.

    • The Bofa on the Sofa

      See my comment below. I don’t think there is ANY basis for the claim that OBs are colder/more unfeeling/more concerned about the bottom line than midwives.

      It’s just that when midwives do it, it gets glossed over.

  • It is a real shame that while health systems talk a good game about being “patient centred” they have a tremendously difficult time actually being patient centred. Far too often it’s “insurance centred” or “provider centred” – some pretty big structural changes are needed. Patients need to be at the policy table – their preferences need to be studied more, their experiences need to be better understood and a lot of the power imbalance needs to be corrected. This is a great post – and applies to much of healthcare.

    • Cobalt

      I think OBs need to be better represented, too. In my experience, a lot of the objectionable stuff (which excludes anything medically indicated) is hospital policy that has nothing to do with individual patient care.

      One nurse watching 5 strips on a monitor means women can’t move around in bed because the belts might shift. It means there’s not enough staff to supervise a woman laboring in the shower. My OB never tried to separate me from my baby for routine exams, but hospital policy did. The Baby Friendly hassles are driven by wooish nurses, admins trying to save money, and LCs, not OBs (although I’m sure there’s an exception somewhere). I’ve had nurses tell me I’m going home soon after my OB sends me in, IN LABOR, because my contractions aren’t frequent enough to meet the “book standard”. How many babies has the “39 week” rule hurt?

      • Medwife

        Well, you can’t really separate hospital policy and limitations vs provider policy and limitations. The one tries to accommodate the other. Say there are two purely elective inductions going, and they were scheduled for today because intricacies of the call/office schedule. You get sent over from the office contracting and 2-3cm, but long cervix, and so you COULD be in active labor, or you might still be in latent labor. They don’t have staffing for another labor, so they tell you to go home and come back when your contractions are more frequent, when in a different staffing situation you’d stay, no problem.

        I’m saying provider instead of OB because as a CNM I work with the exact same limitations. There’s me and the individual patient, then there’s the system within which I work.

        • Cobalt

          Frequently, yes. But.

          In my particular case I went in to the office because I felt a little off and had some light spotting. I was 5 cm and 75% effaced, but not in any significant pain. Since me and my OB know that’s a typical labor pattern for me, she sent me to the hospital for admission to L&D. I got the monitor (widely spaced, erratic contractions I could talk through) and a bunch of “sure you are” eye rolls from the nurse until the hospital doc checked my cervix after 45 minutes and I was at 7.

          When an OB sends someone in, there shouldn’t be pushback from the hospital staff about what labor is supposed to look like. If I waited for 5-1-1 and contractions I couldn’t easily speak through, my kids would have been born in my car.

          • Medwife

            I’m amazed that a nurse would roll her eyes at your contraction pattern being that you were a multip with that exam and bloody show. I should clarify anybody who comes in for “rule out labor” is monitored for at least an hour.

            When a provider sends someone from the office, they’ve seen that person for about 5 minutes and it’s often not possible to tell from that exam that a patient is actually in labor. If someone is 2 cm and contracting but making no cervical change after an hour or two, all other factors being reassuring (fetal status, mom’s comfort level, gestational age, any pregnancy complications) it can be totally appropriate to send someone home who came from an office. It happens all the time.

  • Davidah

    I’ve always thought that this was one of the saddest blog posts I’ve ever read (in retrospect). A bad experience with an OB who wasn’t listening well to what they wanted led this couple to have a home birth which ended in the tragic death of their first-born son. Materna-centered care would very likely have saved their son’s life.

    • KeeperOfTheBooks

      Can you link?
      And yes, while the parents and midwife obviously hold the vast majority of the responsibility for a situation like that, would it have hurt the OB to listen to their wishes courteously, and then approach it all as “What common ground can we find? How can we both compromise?”
      If I, as into the woo as I was, had walked into my OB’s office and been treated rudely/dismissively and consistently so, I would quite likely have been so angry at being treated that way that I would have pressured my husband strongly into paying for a homebirth (he’s an accountant, so he–understandably–is twitchy about dropping $3k plus on something that insurance would cover 100% of in hospital), with, given the circumstances of DD’s last few in-utero weeks, the very strong possibility of my or DD’s death. Instead, he was courteous and respectful, and as a result, by the time we decided I needed a C-section, I trusted him completely and never even once thought it might be an “unnecessarian.”

  • namaste863

    To quote Finding Nemo, ” I don’t want to play the gender card. You want to play a card? How about the “Let’s Not Die” card!”

  • Jocelyn

    OT: Have you guys seen this? http://utahmidwives.weebly.com/

    • Guesteleh

      Well done! I love how it all looks so real and then oops, truth is spoken. The links page is great. But I could swear I’ve heard the names of the “midwives” before even though there’s a disclaimer saying that they’re not real.

  • YES. I dearly hope that people who are concerned with hospital birth realize that midwives really aren’t the answer to everything. I learned the hard way that they can be just as insensitive as any physician, but are less accountable. Finding what is right for you instead of supporting someone elses ideology is very hard if you are trying to cope with labor, and the more care providers are sensitized to the long lasting implications of birth, the better.

    • The Bofa on the Sofa

      I learned the hard way that they can be just as insensitive as any physician,

      Can be? Anecdotally, I don’t think there’s any basis for any claim that they are less insensitive than physicians on the whole.

      • its their whole selling point, so I think the majority of them do actually provide sensitive care. Not competent care, however.

  • the wingless one

    Slightly OT but I was wondering if anyone can point to some articles about epidural safety and how it affects (or doesn’t affect) the unborn baby? I have a pregnant friend I’d like to share with. She is not the woo type but based on a couple conversations I think she has some woo-ish friends who may be feeding her questionable information.

  • Monkey Professor for a Head

    Great piece! This is certainly something I’ve been thinking about lately – why do certain members of the NCB/home birth community have such an us vs them attitude. Instead of jumping straight for the “obstetricians are evil/midwives are the only way” (and I’m sure it runs in the other direction too but the NCB community seems to be a lot more vocal about this), why can’t both sides learn from each other.
    To be honest, I think the medical/obstetrician side has actually been doing this for a while. I don’t have much experience in obstetrics (and I’ve only ever worked in countries with a predominant public healthcare system so that has probably influenced my experience) but when I was in med school (2002-2008) there was a big emphasis on ethics, communication, patient rights, informed consent, anti-paternalism etc. And my impression has been that obstetrics has been the one area where the patient “experience” has been really advanced in recent decades, although I’m sure there’s still room for improvement.
    On the flip side, I think that many in the NCB community (and I know it’s not all, but it’s certainly a significant group) could learn a lot from the obstetrician side. Instead of glorifying “ancient knowledge”, they could be working to improve their practice by conducting proper scientific research. They could be working to collect and present accurate data so their patients can make decisions which are actually informed rather than just telling them that everything will be ok if they trust birth. They could be encouraging higher training standards for home birth midwives, and auditing their practices so they know standards are staying as high as possible.
    Sorry for the ramble, I’ve been up half the night with insomnia, and this is about as coherent as I can make my thoughts at the moment,

    • The paranoia goes back a long way. I encountered it back in the late 60s when I became a Lamaze instructor. At the time, btw, Lamaze was only about breathing techniques,and I’d seen it work quite well in a number of births. In the course, I was the only RN; all the other student instructors were merely women who had no special knowledge of childbirth apart from their own deliveries. The fear and hatred of the medical establishment just poured out of them. I knew most of the OBs they’d used, but would never have recognized them from the descriptions my fellow students gave. In most cases, I came to the conclusion that something far deeper than “insensitivity” was involved; that there was a deep psychological ambivalence to men, marriage, and childbearing that they were completely unconscious of.

    • nomofear

      My husband pointed out the nicest thing about my male, older, Southern, Baptist (found out that he goes to a friend’s church – didn’t come up through business), OB. He never looks at the husband. He directs all conversation at the patient – the woman – to the point of answering any of my husband’s questions whole looking at me. I hadn’t even noticed, but my husband pointed out how nice that was. Especially after the midwives, five years ago, who basically only spoke to him when he was there. I hadn’t noticed that either, for what it’s worth. (Sometimes I think my husband is more feminist than me!)

      • demodocus’ spouse

        My OB would look at my husband if he was answering one of his questions, which is actually pretty cool for him, too, since people tend to address the sighted partner.

  • ForeverMe

    I love this; it’s beautifully written. Its great because it takes a step back and provides a balanced overview of the issues (current and past) along with a reasonable solution. Most of Dr. Amy’s critics don’t know (or understand) that this site *isn’t* written to crow about the infallible greatness of OB’s while trying to make all midwifery (including CNM’s) illegal and ultimately reach that goal of 100% delivery in the c-section assembly line. I’m bookmarking this to counter that sort of misinformation. Plus, its just an awesome piece. Great job, Dr. Amy!

  • attitude devant

    I have always aspired to deliver this kind of care, and I’m willing to bet that you did too. A recent surprise for me: a change to a laborist model in our practice has really facilitated it. We have all the time in the world to discuss options and support watchful waiting (when appropriate), and patients who long said they would want only me at labor have learned that my whole practice is composed of doctors who have their best interests at heart. They always have a rested, relaxed doctor at their disposal, and the doctors are thrilled to be able to give laboring women their full attention rather than juggling office practice, etc.

    • Karen in SC

      Have you seen that the laborist model is reducing c-sections?

      • attitude devant

        no, we haven’t, but our rates were pretty low to start. Is sure is reducing MY stress level…..

    • KeeperOfTheBooks

      Stupid question–what is a laborist model? Does that mean that someone is with a laboring woman (should she so want) from start to finish? Because that sounds really awesome!

      • Karen in SC
        • KeeperOfTheBooks

          Ooof. I can see definite benefits to it in some areas, like always having a doctor there for answering questions/writing orders/emergencies, but I would absolutely loathe not having my OB there when I give birth. I know there’s always a chance he could miss it or not be on call, but that’s a lower chance than the certainty that he wouldn’t be there.

          • GuestRN

            I’m an RN at a community hospital birthplace. All of our providers are independent practitioners, except for a small group of family practice docs. The stress of managing their office schedules with their hospital duties is astounding, I wouldn’t wish their schedules on anyone. To further complicate, we have three OBs who deliver at two different hospitals, and they may have patients laboring at both simultaneously.

            I would not be wrong, I don’t think, in suggesting that they often schedule inductions and cesareans based more on their own hectic scheduling needs and availability than the needs of the patient. Which, in order to attend the deliveries of their patients, is necessary. I’ve heard more than once “get her delivered by X time” from a frantic and overloaded OB.

            It hardly seems to be the best way. For the patient *or* the OB.

          • Daleth

            GuestRN, what you describe seems inevitable with mothers who insist, as some do, that the person who provided their prenatal care be the person who attends their delivery. If you insist on a specific doctor (or midwife) at your labor, that’s just going to happen.

            Is the demand coming from the patients, do you think, or is it just inherent in the way doctors have organized themselves (e.g., solo practitioners have no one to provide backup and have to attend delivery or they don’t get paid)?

          • attitude devant

            The demand definitely comes from patients. But they don’t get it; they haven;t thought it through. If your average first labor lasts over 24 hours (and it does) why in the world would you want to have the (same) provider attending you throughout, when you’re relying on that person to make decisions that require clear-headedness and close attention. Knowing what I know, I’d want someone who was rested and alert.

          • Monkey Professor for a Head

            Im from Ireland and I worked there for 3 years before emigrating to Australia. A major part of why I emigrated was the working hours – at least once a week we would do an “on call” shift which meant you did your normal days work, you then went on call and worked through the night (often with little or no sleep) and then worked your regular day job the next day. Usually this meant working a 34 hour shift with no guaranteed sleep. It’s such a dangerous way of working – both for the doctor and for the patient. There were times towards the end of a 34 hour run where I would start slurring my speech through exhaustion. As nice as continuity of care is, I would never want my family or myself to be looked after by a doctor who is severely fatigued.

            (I should probably specify that I didn’t work in Obstetrics, but similar working hours – or worse- were common throughout most specialties and hospitals in the country. There has been some improvement in hours since I left, with shift lengths meant to be limited to 24hours max, but I suspect that longer hours still happen in some areas. I doubt I will ever work in Ireland again)

          • Ash

            The large OB group here also does labor wards on 24hr shifts. I don’t know if they have a full clinic the next day as well.

          • Daleth

            Yes, exactly. Do doctors ever explain this to women? Once it’s explained I would think for 95%+ of them it would be like, OH DUH!

          • Medwife

            I do 24 hr laborist shifts but thankfully no clinic the next day. I did 48 hr shifts on call as a student and this is way, way, way way way better. I think laborist programs are awesome. It’s built a lot of trust between the providers in my practice, too.

          • Guest RN

            In my particular working environment, I think that it has less to do with patient request and more to do with the doctors being solo practitioners. Needing to deliver someone before clinic opens. Or before their other patient delivers down the street at Hospital B.

            I’m far from a NCB nut, please believe that. But I don’t love to see a patient augmented until and maybe past the point of baby’s distress because of scheduling issues.

            Just throwing an example out there. I don’t think our hospital is typical, and there are many other issues with the unit., some of which are systemic and beyond any individual’s control. I don’t at all believe that most OBs or hospitals are creating the issues I see at my job. Just wanted to point out one pitfall of having stressed, overworked OBs with no backup.

          • Daleth

            Given what you’re describing, and common sense, I’m going to go out on a limb and say maybe at least in areas of the country where there are many OBs, it shouldn’t be allowed for OBs to be solo practitioners. Unless they contract with other OBs to provide backup.

          • Cobalt

            If they schedule deliveries , with informed consent, to be sure they are there for the birth when that’s what the patient wants, I don’t see an ethical issue.

            And I don’t know how OBs with office hours and hospital duties ever sleep. I’m glad I’m not the one in charge of keeping those schedules running!

          • attitude devant

            See, most women start out thinking that way, but what we find afterwards is they were VERY pleased with the idea that the person sitting in house was always available to them. It’s better care, AND more personal care. Truth be told, all the doctors in my group are kind and attentive, and we all hold certain (high) quality standards…

          • Kelly

            I almost had to be delivered by someone from another practice. I did not care. I was just glad there was someone there to deliver the baby. Now, I know not all people would be like that and I had a very straightforward delivery.

  • Laura

    My OB offers this kind of care. 🙂

    • FormerPhysicist

      Mine did too. All 4.

      • Any patient-centered care model requires high staff to patient ratios, and for at least the past 3-4 decades, hospitals have been trying to cut staff wherever possible. Anywhere that a single nurse or midwife is covering three rooms with actively laboring women means that two of them will not be getting support from her at any given moment.

        I saw this very clearly when I had my hip replaced. Staffing patterns were based on the assumption that I would have a relative in almost constant attendance; it was barely possible for the staff to pass out meds, change dressings, and do the charting. There was never anyone available to help me wash when I was bedridden, or to assist me to the toilet when I was newly ambulatory. And I could see that the few staff on duty were really very busy, not on “coffee breaks”.

  • Montserrat Blanco

    I really love this post. Thank you for writing it.

  • KeeperOfTheBooks

    I LOVED this piece. It’s completely spot-on. It also pretty much describes why I love my OB’s practice: he is courteous, he explains the “whys” of anything he recommends, and he’s flexible in areas that he can be flexible. At the same time, he’s a top-notch doc. I tell anyone who’ll listen about my experience with him partly because it was just that good, but also to counter the “My Evil OB did X” stories you hear all. the. time.

  • MHAM

    This might be my favorite thing that your have written. I love it! Yes, yes, yes! There’s no reason we can’t have top of the line medical care AND all the warm-and-fuzzies, too.
    I have been saying for years that if we improve maternal care and satisfaction in the hospital, it will undermine the market for homebirth. Also, by fleeing the hospital setting in favor of homebirth you’re not only putting yourself and your baby at risk, you’re also doing nothing to provide feedback to the medical system and improve standards of care.
    I travel in some pretty crunchy circles and some of my friends were shocked that I chose to have both my babies in a hospital. And they were further shocked that we had a great experience both times. I had wonderful doctors and nurses who took excellent care of us and I have told anybody who will listen to me. I didn’t have to “fight” anybody to get the kind of birth that I valued and we had an excellent team making sure that we were safe and healthy every step of the way.
    The Business of Being Born was made in 2008. That was seven years ago, people. Stop using it as your point of reference for how hospital births are managed. In many places, a lot has changed since then. My hospital births looked nothing at all like what was portrayed as the norm in that documentary.

    • The Bofa on the Sofa

      The Business of Being Born was made in 2008. That was seven years ago, people. Stop using it as your point of reference for how hospital births are managed. In many places, a lot has changed since then.

      Actually, a lot had already changed long before they made that movie, right?

      Because we still hear about shaving and enemas, despite the fact these haven’t been routine since when? The 1990s?

      • MHAM

        Word.

      • Cobalt

        Earlier than that. Most of my siblings and cousins were born in the 80’s, and none of their moms had either even offered.

        • Cobalt

          And to add: there are women going into L&D freshly waxed and possibly having done an enema at home. The first because of the current trend in pubic hair fashion, the second because they’ve heard it might prevent pooping during delivery.

          Now, giving women the idea that there are pubic beauty standards other than recently enough washed in the delivery room is a whole new oppression.

          • Inmara

            Sadly, I found out in local birthing boards that shaving and sometimes also enemas are very “encouraged” in our hospitals. I understand that it’s easier for midwife or OB to handle things without a bush on involved body parts, but they have to deal with it for few hours, while I would have to deal with ingrown hair for at least a week. Maybe it’s only some midwives and OBs, but it was mentioned in labor stories so matter-of-factly that I’m afraid it’s really expected by default.

          • Cobalt

            That’s odd, because one of the reasons shaving in hospitals stopped was because of the increased infection risk due to the inevitable microcuts on newly shaved skin. Even when I had hernia surgery (below the hairline) they only clipped, and they were cutting me open and digging about.

            And enemas only slightly reduce the odds of pooping in labor. They dramatically increase the odds of spraying dirty saline if any gets left behind.

            ETA: This is in most of the US. Anywhere else, I don’t know what the usual is.

          • Inmara

            I’m not in US, but thank’s for the tip about infection risk – I will keep this in mind and rather try to trim something down there if feeling it’s necessary (I guess my husband will have to lend me his trimmer and helping hand, ha!)

          • Medwife

            I would much rather deal with hair on my patients than the gnarly folliculitis I see with all this shaving and waxing. Eek.

          • toni

            Wish I hadn’t looked that up just now! ick!
            Maybe sugaring is better(?) that’s what I’ve always done and never had any problems/irritation. I do have the skin of an elephant though. not at all sensitive

          • Michele

            With my planned C-section, my patient prep instructions even specified not to shave the area for a certain number of days beforehand.

          • araikwao

            There’s a place near me that advertises “pregnancy waxing” amongst other painful, waxing-related services. I didn’t know it was a thing until then, but have also been seeing so many clipped/shaved/in other ways denuded intimate regions on my clinical rotations lately..it is the norm, I dare say.

          • Roadstergal

            I’ve never been waxed – maybe it doesn’t hurt as much as I fear, but the pain vs benefit tradeoff doesn’t seem worth it to me. I did laser, which means I don’t have to shave as often, and the docs who have seen me naked have been nice enough not to comment on the hardwood floor or the Christina. (Although the dermatologist who gave me my first full-body mole-check this past week did compliment me on the Robot Devil tattoo, as I am a massive Futurama fan.)

          • Cobalt

            That laser business is awesome- no more saddle sores.

          • Roadstergal

            It’s just so variable in how it works. My legs? I trim off a few hairs maybe once a month, now. Underarms, barely made a difference. Privates, about halfway between in outcome. And I am one pasty white girl, so I’m the optimal client.

            I’ve never liked body hair. I went to a women’s college where I dutifully let it grow out, to be a Good Feminist, but now, screw it, I like it this way.

          • Cobalt

            I actually know someone (happens to be a guy) who shaves everything but eyebrows (too odd for other people- made casual conversation difficult) everyday. Lasering wasn’t enough. He just can’t stand the sensation of having hair.

            I had actual saddle sores- recurrent folliculitis from summer riding. Now I don’t, and I love it. Underarms would be nice too, if I ever have the spare cash and time.

          • Amy M

            I’ve done waxing and laser—while I got the wax done professionally sometimes, I also did it myself at home. I didn’t find all that painful–the redness and stinging did last a bit longer than the laser. Obviously, waxing lasts longer than shaving and can reach parts that a razor can’t easily, but if you can swing it, laser is a better long term solution as far as I can tell.

      • Sullivan ThePoop

        I had a baby in 1989 and 1991. Neither time did they shave me I did get an enema with my second but it was because I had to go, couldn’t, and it was interfering with the baby coming down.

      • attitude devant

        I’ve been present at hospital births since 1983. Never seen either. (patients sometimes do request enemas….)

        • NoLongerCrunching

          In hindsight I actually wish someone had suggested an enema. I labored in water and after my daughter was born (thankfully above the water line) … well let me just leave it at I wish I had had an enema.

      • fiftyfifty1

        Not since the early to mid 1970s. It’s been 40 years.

      • An Actual Attorney

        Why shave when you are already waxed??

    • fiftyfifty1

      “I have been saying for years that if we improve maternal care and satisfaction in the hospital, it will undermine the market for homebirth. ”

      I have been saying the opposite for years. I do agree with Dr. Tuteur that we should always strive for a patient-centered experience, because that’s the right thing to do in any area of medicine. But I don’t believe that hospitals are driving women away. It’s the false promises and lies of NCB that are luring them away like the Pied Piper. My local hospital has it all. You can get a MRCS. You can have a CNM waterbirth. There are epidurals and birthing balls and squat bars and even a free doula program. Each room is like a luxury hotel, and all the scary looking medical stuff is hidden away behind walls that flip over to reveal it only if needed. Our maternal satisfaction rates are through the roof. But there is still a birth center run by crazy-ass CPMs down the street, and despite a recent death there, they have no lack of business. The business of being born, indeed.

      • attitude devant

        ^^^^^this

      • Bugsy

        Yes. The hospital maternity wing where my son was born resembled a luxury hotel. It was ab-so-lutely wonderfully mom-centered, with the advantage of having the OBs and full medical staff also available.

        • Daleth

          Same here. Even the food was amazing.

        • KeeperOfTheBooks

          Mine wasn’t quite that awesome–well, it could be, but you’d drop a non-insurance-covered $400/night for the room with the Jacuzzi and queen-sized bed, and I wasn’t quite that interested in it ;)–but it was pretty darn good. For me, the epitome of how nice it could be was summed up in the first time I got up to take a shower, and got back into my room to find my bed made with clean sheets and arranged at a comfy angle (pillows fluffed, no less!), DD in a clean diaper and interested in eating, my water glass refilled with ice water, and the lovely patient care tech who did all this asking assiduously if she could get me a snack or some juice/coffee/whatever.
          AWESOME.

      • Lizzie Dee

        I agree 100% that it is the false promises that are betraying women. Yes, young women now do have choices that my generation barely dreamed of – but you can;t “choose” a safe birth.

        There was a recent (very poor) article in The Guardian bemoaning the increase in maternal deaths, the high stillbirth rate here in the UK. Guess what? Caused by high-tech birth and too many ceasareans. The resulting discussions focused on not very reliable statistics, but there was also a strain of “Well, not many die.” It is as if the fact that birth can be probemmatic is still there in a fatalistic manner, but brushed aside as inconvenient.

        Too many. Who shouldn’t. Given my own disastrous experiences, the lack of curiosity about what goes wrong – and the blaming of women – infuriates me. I am all in favour of care that absolutely centres on women’s wishes and listens to what is important to them, but not just on birth as an experience. You don;t have to focus on the horrors to grasp that it is still hazardous and unreliable. Educated choices work best, and I would like the fantasies of NCB to be seen more clearly for what they are: magical thinking.

    • MegaMechaMeg

      Be fair, the business of being born’s single hospital birth was a baby requiring immediate resusitation after meconium aspiration with a terrified tearful mother clinging to the rails of her bed not knowing if her baby was going to live. You know, just like most hospital births.

      • FarAwayStars

        Thank goodness it was a hospital birth. I’d hate to see how a homebirth midwife would have handled aspiration and resuscitation.

        • MegaMechaMeg

          Well obviously meconium is something that could only happen in a hospital as a direct result of being in a hospital.

  • Excellent post, Dr. Amy.

  • AllieFoyle

    Shabby chic — hilarious!

  • Roadstergal

    Great piece. Some folk like the support and feel of hard, utilitarian furniture, and some like to wallow in a big, squishy couch.

    And the soft, squishy, hippie-chic furniture should be held to the same standards as the drab, utilitarian furniture – none of this “well, sometimes a sofa just collapses and kills someone, nothing that can be done about that.”

  • Cobalt

    🙂

  • PickAUserNameForDisqus

    This may be my favorite piece you have ever written. Honest of the shortcomings at both end of the spectrum, and with a reasonable middle-ground. One of the best parts of this read is that anyone who refuses to see the shortcomings of either model, for example they disagree or want to argue about the contents of the first three paragraphs, has identified themselves as entrenched in their thinking, and unable to recognize that the focus should be on the woman. Thank you! Thank you!

    • fiftyfifty1

      “anyone who refuses to see the shortcomings of either model, for example they disagree or want to argue about the contents of the first three paragraphs, has identified themselves as entrenched in their thinking, and unable to recognize that the focus should be on the woman.”

      Meh, I’ll sign up to be that person then. Yeah, woman centered care. Yeah, it’s the right thing to do. I suppose. Like it is in every area of medicine. And yet it does make me throw up in my mouth a little bit at times. Because our local hospital has it, it really does. Like I said above you can get everything from a MRCS to a CNM waterbirth to a VBAC. And in fancy birthing suites nice enough to be a luxury hotel. And maternal satisfaction rates are sky high. And that’s nice. It’s also pretty self involved and silly. We have millions in this country who are still uninsured. 10 miles away are nasty neighborhoods and a hospital with stained carpet in the halls, and cramped bathrooms without tubs, but damn good doctors and nurses, although not likely to kiss your ass and court your consumer power.

      • Cobalt

        I completely agree that the consumerism aspect, especially when it gets to where decor becomes a major issue, does get ridiculous. I call it an NCB movement side effect though (trying to out-pretty homebirth and meet the demands of women who’ve “done their research”), whereas patient centered care should be about respect, ethics, outcomes, and a good night nursery.

      • PickAUserNameForDisqus

        I agree with @disqus_U69Bh1fy4T:disqus, patient-centered care isn’t about the pretty factor, it’s about the respect, ethics, outcomes, and above all else communication. And if the conversations can be done before urgent and emergency situations, all the better.

  • MegaMechaMeg

    I love the idea of birth plans. I love the idea that I can fill out a form that indicates that I want anesthesia offered quickly, I have a scientific mind and I prefer technical explanations when possible and my tolerance for risk is small so please feel free to suggest a section should things look even a little bit dodgy. I think my care would be optimized if my care providers know these things about me. I am a unique case and my goals are different from somebody who wants a large family and knows that they tolerate labor well. I hate how birth plans have turned into shorthand for unrealistic expectations. My SIL is a labor and delivery nurse and she tells me that when somebody walks in with a birthplan they pretty much get the OR booked because half the time it ends in a section.
    I want there to be an efficient way to communicate your goals without having to worry that somebody is going to think you want a live dolphin show at the moment of crowning and a string quartet playing Debussy during the first latch.

    • PickAUserNameForDisqus

      I wish a birth plan was more of a checklist of things that have been discussed. Such as “I have talked with my [birth professional person], and partner about all the strategies for pain relief” [checkbox]. I have talked with my [birth professional person], and partner about the standard delivery practices at my [place of birth]” [checkbox]. I have talked with my [birth professional person], and partner about what events would make my birth not match the standard birth at my [place of birth]” [checkbox]. I have talked with my [birth professional person], and partner about newborn care practices at my [place of birth]” [checkbox]. Etc Etc. I think when moms understand the standards, and reasons for deviation before things get urgent they then are participating in maternal-centered care. Also, all of these fraught topics should be conversations between mom and the people actually providing the care. AND, when moms hear from their providers that “no, we never give enemas”, and “of course you can move around unless X,Y,Z has happened, and here are the reasons why changing positions then would be problematic, and let’s talk about strategies to help you if that happens”, etc etc – then moms suddenly realize that the strange NCB myths about OBs are almost always just that: myths.

      • PickAUserNameForDisqus

        Feels weird to reply to my own comment, but I wanted to add a real life example of this I have seen. I had a mom friend totally anxious about hospital birth because she has been made afraid of newborn care practices. The old myth that her “baby, even if healthy, would be taken away from her after birth”. I got her in touch with he L&D nurse who sent the two of us the following, which really helped the mom understand the normal flow of newborn care, and how to talk about alterations she was interested in. It turned the conversation from scary hypotheticals, to reality: “The standard newborn procedures are:
        Vitamin K injection and erythromycin eye ointment, given within the first hour after birth in the mother’s room. State regulations require that the meds be given within the first hour of life. Parents can request that this be delayed or decline completely. If they decline completely, they will be asked to sign a declination statement.

        They newborn bath is typically done in the nursery, but can be done in the mother’s room by request. This is usually done within the first few hours after birth, but can be delayed as long as the parents wish. If the baby comes to the nursery, it will probably take about an hour because the infant is placed under a warmer to warm back up after the bath. Depending on the nurse, most are okay with the baby doing skin to skin with mom after a bath in the room to maintain their body temperature.

        All of the babies are weighed at midnight. Babies typically come to the nursery to be weighed and as long as the nurse knows that mom wants the baby back right away, shouldn’t take long… 10-15 minutes max. If mom requests, the weight can typically be done in the room as well.

        On the morning before discharge, usually around 4 am, the state newborn screening test (which is a blood test that goes off to the state lab and tests for a variety of rare newborn diseases)and a bilirubin blood test to check for jaundice (results will be available before discharge) are drawn via a heel stick. Usually as this time, babies also receive the hepatitis B vaccine and have the state mandated congenital cardiac screening (which sounds scary but is just a pulse oximeter probe (the same probe with red light that is typically placed on mom’s finger during labor) placed on the right hand and a foot to make sure that blood is oxygenating the way that it should). One final thing done on the early morning before discharge is the state mandated hearing screen. This is the only thing that, to my knowledge, cannot be done in mom’s room because the equipment is large and cannot be moved. This is the other time that baby is typically out of mom’s room for a more extended period of time (for the blood work, hep B, cardiac screen and hearing screen to be done). The hearing screening machine is very sensitive to sound and movement, so it is best done when baby is in a deep sleep, so it can go quickly or take a bit more time, depending on baby’s state. As far as this goes, depending on what is going on in the unit, it is most likely possible for everything but the hearing screen to be done in mom’s room if she wishes.

        Of course it is not recommended, but anything can be declined. For most things that are declined, the parents will have to sign a declination form. Some physicians are more gentle than others about parents declining medications or tests, but ultimately it is their child and their decision.”

        • Guest

          At the two hospitals where I gave birth (within the last five years), one find everything listed above in mom’s room. The other did everything above except the hearing test. So there’s that…

          • Amy M

            Yes, the hospital where I had my babies was similar, but they did the hearing screen and carseat test somewhere other than my room. They did take the babies right away to be checked–preterm twins–but determined quickly that they were fine and went to do all the shots/weights/bath and whatnot. I was getting stitches, but my husband went with the babies, so that was a logistic thing, not trying to keep me apart from the. He got some good photos.

          • Cobalt

            I was up and walking very quickly after delivery each time, but only one hospital (my first) had nurses who said I couldn’t follow the baby to the nursery for the initial exams, bath, etc. That hospital had a lot of restrictive policies unrelated to individual patient care and medical circumstance though, the kind of stuff Dr. A is calling out here. I want to note, though, it was hospital policy with nurse enforcement. My doctor was totally fine with me following along.

          • PickAUserNameForDisqus

            Another important reason to have a conversation with providers who should know the policies at the birth location. IF a mom is in a place where she has a choice of locations then knowing that one place has restrictive policies allows mom to choose another hospital if the restrictions matter, OR allows her to make a complaint prior to being the new postpartum mom.

          • Cobalt

            Definitely, and I wish I had known that going in to my first delivery. I had actually sat with friends and relatives for theirs, but none were at that hospital and none were so restrictive. I just naively assumed I had a good general idea of goings on, and was completely wrong both about the hospital experience and about my own internal experience.

            By my last kid, I was hospital shopping before I committed to an OB, and actually changed doctors partly because of the results of my maternity tour.

            I’ve also found that a lot of OBs don’t know or aren’t really aware of a lot of the patient management protocols, probably because they aren’t involved in creating, enforcing, or dealing with those rules.

          • Elaine

            The hospital where I had my first definitely hassled us about going with the baby for the exams. Every time they wanted to whisk her away, it was a fight. Most of the doctors were willing to work with us, except for one neonatologist who was pretty condescending overall. This was in 2011. We had our second last year at a different hospital and zero problems there.

        • just me

          So none of this gets done in a home birth? Scary.

          • Cobalt

            Part of the reason for the higher death and damage rate. You could theoretically have your baby at home and then go to the hospital for all that, but that’s not what happens unless someone figures out the baby is already in trouble.

          • just me

            So this really bothers me. It’s required by law for the baby’s health and safety, oops, except if the baby is delivered at home.

          • Cobalt

            Required by law to be offered as standard care by medical providers. No hospital shortcuts to save money risking babies’ health. Parents can decline any of it. The reasons for declining are generally the same “educated” reasons that drove them to forgo all other basic medical care for their baby.

            Bothers me, too.

          • NoLongerCrunching

            If the mother takes her child to a real pediatrician, I am sure the pediatrician will help figure out how those things can be done. I gave birth to my youngest in a reputable CNM-run birth center, and we got all that stuff done. Do homebirth midwives even offer vitamin K shots?

          • Cobalt

            Would homebirth parents want Vitamin K shots?

          • The Bofa on the Sofa

            Of course not, because babies born at home never bleed.

        • MHAM

          See, this kind of interaction constitutes ACTUAL research (vs. horror stories online or in outdated books). It’s easier to Google something than it is to reach out to a stranger at a hospital or a doctor in a hurried appointment, but it is so beneficial. THIS is doing your research, not reading umpteen blogs and BabyCenter forum discussions.
          When I was pregnant with my first I learned that just about every single scary “oogie-boogie” thing about the hospital was no longer standard practice. I learned this because I made it my business to learn how MY hospital and MY doctor were doing things. And how they were CURRENTLY doing things, not how they did things 10 years ago when so-and-so’s third cousin had a baby there.

      • demodocus’ spouse

        It has to be really serious for you not to be able to move during most of labor, at least in my hospital. I wasn’t allowed to get off the bed because I had the Pitocin and magnesium going (I think magnesium was the one that made me a bit loopy), but I was still able to roll to either side, sit up, or lay down as I pleased.

      • KarenJJ

        “I wish a birth plan was more of a checklist of things that have been discussed.”

        That’s what I did. I just printed off a bunch and showed them to my obgyn to get his opinion. His eyes pretty much rolled the entire discussion and he explained why he recommended a vitamin K shot instead of oral, but his answers satisfied me and I didn’t bother with the birth plan.

    • SporkParade

      Agreed 100x! The most frustrating part about my [hypnobirthing] childbirth class was that we got this form birth plan, and then we were expected to use it to determine our preferences with ZERO understanding of what makes something standard procedure and with no reference to what standard practice at the local hospitals are.

    • DaisyGrrl

      After checking several hospital websites in my province, I liked this birth plan the best: http://www.qch.on.ca/Content/File/Childbrith%20Centre/NEWB%201091-11-06(D).pdf

      Reasonably short and sweet, all info is standardized so the medical staff know where to look for each piece of info, and no set space for stupid stuff the hospital doesn’t do (enemas, routine episiotomies), or woo (standard treatments, vit k, etc). The patient has space at the top for their most important info, and there is no implicit judgement surrounding any of the choices mentioned. Now, this hospital is either pursuing their BFHI status or has it, but nobody’s perfect.

  • seekingbalance

    beautifully put. a peace offering for all!

    • Cobalt

      It’s not really different than what she’s been saying all along though, just condensed and with a slightly softer tone.

      • The Bofa on the Sofa

        It’s certainly not inconsistent with anything she’s said before.

  • PrimaryCareDoc

    I love this!

  • SporkParade

    In order for that to happen, society needs to start relating to mothers as responsible adults. The most disheartening part of pregnancy and new motherhood for me was the feeling that, suddenly, it was okay to talk down to me and to ignore my needs and well-being because there was a baby involved.

    • Amazed

      Oh yes. And the breast warriors, anti-pain relievers too often find the ground ready for them by well-meaning family and friends. Really, a few days ago I was having a coffee and a fuzzy drink – gasp! – with a friend who was getting a haircut and a lecture from those around her how it was bad for the baby – she’s in the sixth month. Superstitions at their best!I But it’s for the baby! Thankfully, her vanity and sanity of mind prevailed, as well as the knowledge that a bar of chocolate from time to time won’t make the kid obese and stupid.

      I asked her what she was planning to do when she took her maternity leave and she told me, “I’ll tell you what I WON’T be doing. I won’t scare myself with reading horrors on the internet anymore! I tried to educate myself and I found that, apparently, a C-section is the end of the world.” And then, in a lower voice, “You don’t really believe it’s bad for the baby, do you?”

      • NoLongerCrunching

        Do you mean fizzy? If not, what’s a fuzzy drink?

        • Amazed

          Oh, I absolutely mean fizzy. I must admit I don’t proofread my internet writings. Too much of this in RL!

          • Who?

            I just assumed you were in New Zealand, and about to have fush and chups.

            Australian joke, sorry.

      • Roadstergal

        All I can think of when it comes to worrying about the baby’s experience during a C-section is wondering whether, post-birth, babies prefer to be put into backseat car seats via the door, or by being squeezed through a cracked-open window…

      • SporkParade

        Sadly, I was including the AAP among the persons and organizations that think having a child = being a child.

      • araikwao

        No way! Chocolate consumption is totally what made my kids so smart! At least, that’s what i want to believe!

      • Daleth

        This is research I can get behind: apparently eating chocolate during pregnancy makes for more cheerful, livelier babies:

        http://news.bbc.co.uk/2/hi/health/3604275.stm

        • Mac Sherbert

          I’m pretty sure chocolate is what lead to me having a 9 lb. plus baby. lol Actually, choc-it is still her favorite thing. And I would describe her as being a very demanding and very aware baby.